Repeated warnings
Each one is a single concern, raised with the same organisation in two or more coroners' reports at least six months apart. Nemotron Super judged every match to be the same or a closely related hazard, and both quotes are checked word for word against the reports.
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At least
32 chains, most recent report first. The order is by date only; there is no ranking of organisations.
- Lack of regular first aid training among custodial staff
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high - Overly rigid right care right person policy leading to deployment delays
College of Policing · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · high - Delayed discharge due to lack of suitable care home placement
Department of Health and Social Care · National body
4 reports · 2 coronersClosely relatedConfidence 0.90 · high - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Widespread new psychoactive substances in prison
His Majesty's Prison and Probation Service · National body
5 reports · 4 coronersClosely relatedConfidence 0.80 · moderateNo published response to an earlier report - Inappropriate prison environment for mental health treatment
Department of Health and Social Care · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 3 reports · 3 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- Lack of awareness of fatal side effects of clozapine
Department of Health and Social Care · National body
2 reports · 2 coronersIdentical hazardConfidence 0.95 · high - 2 reports · 2 coronersClosely relatedConfidence 0.90 · highNo published response to an earlier report
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · highNo published response to an earlier report
- Lack of GP awareness of prescribed medication
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.90 · high - Inadequate out-of-hours psychiatric response and unsuitable section 136 suite
NHS England · National body
2 reports · 2 coronersClosely relatedConfidence 0.85 · high - Missing mental health hand‑over in custody
NHS England · National body
3 reports · 3 coronersClosely relatedConfidence 0.80 · moderate - 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- 2 reports · 2 coronersIdentical hazardConfidence 0.90 · high
- Unlicensed DNP weight loss drug toxicity
Home Office · National body
3 reports · 3 coronersClosely relatedConfidence 0.85 · highNo published response to an earlier report - 2 reports · 2 coronersClosely relatedConfidence 0.80 · moderate
- Poor record keeping in missing person investigations
Department of Health and Social Care · National body
3 reports · 3 coronersIdentical hazardConfidence 0.90 · high - Inadequate seizure recognition and post‑seizure behaviour training
College of Policing · National body
2 reports · 2 coronersClosely relatedConfidence 0.90 · high